Cognitive impairment -- what is it?

Cognitive impairment is a problem many of our difficult children have which adversely affect school performance. This is one of the better definitions I've found for it.

Cognitive impairment may be experienced in different ways. Let's look at how each of these cognitive problems may be manifested.

Attention

Some people report that they have difficulty paying attention when people talk and give directions. Others find it hard to concentrate on what they read, and find that they loose track of the important points, especially when reading longer passages. They may find it hard to focus on one thing when other things are happening. They may get distracted or conversely, become so involved in one thing that they fail to attend to something else that is happening. Multi-tasking, for example, answering a customer's question while operating the cash register, becomes difficult because they have to divide their attention.

Memory

The ability to remember and recall information, particularly verbal material, is often a problem. Directions may be forgotten, or the ability to recall what has been read or heard may be reduced.

Most people who are depressed or in an affective episode will have difficulty with attention, concentration and thinking clearly. Those people with persistent mood problems, and those who have psychotic symptoms are more likely to continue to experience cognitive problems between episodes.

Cognitive problems can affect people of all ages. There is evidence that cognitive problems are most pronounced in the early phases of schizophrenia and then for many people level off, not getting better or worse. Since schizophrenia usually starts in adolescence or young adulthood, that is the time when the most dramatic decline in cognition may be seen. However, since that is the time when psychotic symptoms like delusions and hallucinations also start, the cognitive problems may be overlooked by a family until the psychotic symptoms stabilize. For children and adolescents, a drop in school performance may be the first sign that alerts families that something is wrong.

Cognitive problems are very common in older adults with depression. Sometimes it can be difficult to sort out whether the forgetfulness is due to depression, normal aging, or another condition like dementia. The mental health professionals will ask questions and do tests to answer that question. Many people experience memory lapses as they get older, but when someone is depressed the forgetfulness is more severe.

People with mental illness who abuse drugs and alcohol are very likely to experience cognitive problems. Drug and alcohol abuse alone can impair attention, memory and thinking skills. If substance abuse is combined with mental illness the cognitive problems can be even worse.

Most people do not have trouble remembering routines they have learned, but they may find that they do not hold onto new information as well as they used to.

The ability to process and respond to information

Family may notice that response times are slower or that it takes longer to register and understand information. Speech production can also seem slower and even though it may only be half a minute, that can seem like a long time to wait for a communication when you are trying to have a conversation with someone.

Thinking skills

Critical thinking, planning, organization and problem solving are often referred to by psychologists as the executive functions, because those are the skills that help you act upon information in an adaptive way. Take the example of cooking a meal.Even if you know how to cook each dish, to actually serve a dinner you have to plan ahead to have all the ingredients, organize and manage your time so each dish is finished at the same time. You also need to be able to adapt your plans if problems arise, like the oven does not work or an ingredient or type of pan is missing. People with mental illness may seem less able to think of alternate strategies for dealing with problems that arise, or they may have difficulty coming up with a plan, or find it hard to listen critically to new information and know what is important and what is not.

Cognitive impairment: The impact on daily functioning

When people have trouble paying attention, remembering and thinking clearly, it impacts on their ability to function in the community, at school, at work and in relationships.

Community: Impairments in memory and problem solving are associated with greater problems living independently. In fact, it has been shown that for people with schizophrenia, cognitive abilities are more linked to successful independent living and quality of life than clinical symptoms. It is easy to understand that the ability to solve problems and remember verbal information is critical for negotiating transportation, home management, shopping, finances, health and psychiatric rehabilitation.

School: The school years are formative years, when the mind is developing and one's knowledge base and critical thinking skills are broadening. Unfortunately, mental illness often starts before people have finished this educational process. The problems with attention, concentration and thinking can make it very difficult to keep up with school work, and even students who once excelled may become discouraged by the lost time, or their declining grades. When students fall behind in their academics, they may start to view themselves negatively, and prefer to quit rather than keep exposing themselves to more academic failure. They also lose the opportunity to consolidate good study and learning habits, or worse, a poor learning style may develop. People with mental illness who have dropped out of school are at a disadvantage when competing for jobs yet the cognitive problems can make it difficult to complete the necessary degrees.

Work: Research has demonstrated that people with mental illness who have difficulty with memory, problem solving, processing speed, and attention are more likely to be unemployed or have a lower occupational status. In many ways this is not surprising. Critical thinking has been identified as one of the most important skills that people need to compete in the modern workforce. Yet critical thinking/problem solving is often impaired in people with persistent mental illness. The problems that can arise at work when someone has difficulty paying attention, concentrating and remembering are also obvious. Most jobs are not just rote and repetitive, but require people to remember new information or deal with changing demands. This is difficult when cognition is not working well.

Relationships: One of the things that makes personal relationships rewarding is the give and take of support, caring and concern. People want others to really listen and pay attention to them. When someone with mental illness is not able to attend to or remember what their friend is saying, their friend may feel hurt or not listened to. At work, colleagues or bosses may think the person with mental illness does not care - or is lazy - when in fact it may be that they are not cognitively able to perform. The ability to pay attention, be focused and not get distracted is important for social functioning.